life woman enhanced benefits claim form - Great Eastern Life

AUTHORISATION LETTERFor Claimant’s completion :I would like the claim cheque (if claim is approved) to be :posted to me via my correspondence address.collected by my Servicing Life Planner, (NRIC No.: )Signature of Claimant : Policy No. :Name of Claimant. :Handphone/ Contact No. of Claimant. :NRIC of Claimant :Date:For Servicing Life Planner’s completion (if Claimant has authorised you to collect the cheque)I would like the claim cheque to be: -Collected at Customer Service Reception Counter at Ground Floor, Great Eastern Centre.(Please note that the cheque will be posted to the Claimant if it is not collected by the next working day after the collection date.)Dropped into my GSM Box No.at GE@Changi.*Dropped into my GSM Box No.Dropped into my GSM Box No.at GE House.*at Nankin Row.** Notes:-1. Option is available only if there are no outstanding documents to be submitted. Cheque will be delivered to your GSM Box the next working day after 12pm.2. For Life Planners who have opted for collection of cheques at Customer Service Reception Counter at Great Eastern Centre, Claims Department will contactyou when the cheque is ready.Signature of Servicing Life Planner :Name of Servicing Life Planner :Agent No. :Contact No. :For Official Use :Claim Officer : Extension No. :Pending documents / comments :Cheque / Letter released by:-Signature :Name :Date :Cheque / Letter received by:-Signature :Name :Date :The Great Eastern Life Assurance Company Limited (Reg. No. 1908 00011G)The Overseas Assurance Corporation Limited (Reg No. 1920 00003W)Claims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sgLast updated: 30042009

CLINICAL ABSTRACT APPLICATIONImportant Note: (i) This form is required for the application of medical report from hospital/clinic and should be completed by the patientor the patient’s parent (if patient is below 21 years of age) or the patient’s next-of-kin (if patient is deceased).(ii) For request of medical report from hospital, this form is to be submitted to the Medical Records Department of thehospital.* Please delete accordinglyTo (Name of Doctor & Hospital/Clinic) Date :Dear SirName of Patient :NRIC No:Re : Application for Medical ReportI hereby authorise you to furnish * THE GREAT EASTERN LIFE ASSURANCE COMPANY LIMITED/ THE OVERSEAS ASSURANCECORPORATION LIMITED with a detailed medical report on the above named patient. This report is required for an insurance claim. I confirmthat a photocopy of the signed original Clinical Abstract Application form is as valid and effective as the original Clinical Abstract Applicationform.Yours faithfully[ ][ ]Signature of *Patient / Patient’s Parent /Patient’s Spouse / Next-Of-Kin[ ][ ]Signature of witnessName : Name :NRIC No : NRIC No :Address : Address :The Great Eastern Life Assurance Company Limited (Reg. No. 1908 00011G)The Overseas Assurance Corporation Limited (Reg. No. 1920 00003W)Claims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sg

LIFE WOMAN ENHANCED BENEFITS CLAIMS- CLAIMANT’S STATEMENTImportant Note: (1) The Overseas Assurance Corporation Limited hereby referred to as “The Company”.(2) To be completed by the Policyholder.* Please delete where appropriate1 POLICY (IES) ISSUED BY THIS COMPANYOverseas Assurance Corporation Policy No(s).:2 DETAILS OF POLICYHOLDERTitle:Name(According toNRIC/ Passport):Mr/ Mrs/ Madam/ Ms/ Miss/ DrResidentialAddress:Postal Code:NRIC No:E-mail Address:Occupation:Home Tel:Office Tel:HP/ Pgr No:3 DETAILS OF LIFE ASSURED (if different from (2))Title:Mr/ Mrs/ Madam/ Ms/ Miss/ DrName(According toNRIC/ Passport):ResidentialAddress:Postal Code:NRIC No:E-mail Address:Occupation:Home Tel:Office Tel:HP/ Pgr No:4 NATURE OF CLAIM AND RELATED DETAILS(a)Please tick the appropriate box for the benefit that you are claiming:Carcinoma in situ of the breastCarcinoma in situ of the cervix uteriSLE with lupus nephritisHysterectomy required as a result of cancerEctopic PregnancyDown’s syndromeSpina bifidaTetralogy of FallotTransposition of the Great VesselsDisseminated Intravascular coagulationReconstructive surgery of facial disfigurement due to accident or assaultHospitalisation due to complications of pregnancy or childbirthIncubation of new-born baby for more than 5 daysDateSignature of PolicyholderThe Great Eastern Life Assurance Company Limited (Reg. No. 1908 00011G)The Overseas Assurance Corporation Limited (Reg. No. 1920 00003W)Claims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sgCLMLWBCLA/V1/20071

(b)Describe fully the symptoms for which the Life Assured consulted a doctor.(c)How long did the Life Assured have the symptoms before he/ she consulted a doctor?(d)Date when the Life Assured FIRST consulted a doctor:Day Month Year(e)Name and address of the doctor whom the Life Assured first consulted for the illness or injury:(f)If consultation was for illness, describe fully the extent and nature of the Life Assured’s illness.(g)If consultation was due to an accident, describe fully the nature of the Life Assured’s injuries and how it happened.(h) Has the Life Assured previously suffered from or received treatment for a similar or related illness? YES / NO*If “YES”, please give full details.(i) Does the Life Assured suffer from any other medical condition? YES / NO*If “YES”, please give details:Description of Medical ConditionDate(s) Diagnosed(DD/MM/YY)Name and Address of Attending Doctor(s)DateSignature of PolicyholderClaims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sg2

5 RECORD OF MEDICAL CONSULTATIONS(a)Provide the details of any doctors who have been consulted in connection with the Life Assured’s illness:Name(s)Name(s) of Clinic(s)/ Hospital(s) and AddressDate(s) of First Consultation(b)Provide the name(s) and address(es) of the Life Assured’s regular doctor(s).Date(s) of ConsultationName(s) Address(es)(DD/MM/YY)Reason(s) for Consultation6 OTHER INSURANCEIs the Life Assured claiming from any other insurance company or other sources in respect of this illness/ injury?If “YES”, provide the following information.YES / NO*Name of InsurerDate of Issue Sum Type of Plan Claim Claim ClaimAssuredAmount Notified Paid(YES/ NO) (YES/ NO)DECLARATIONI declare that the answers given by me in this Form are in every respect true and correct and that no material information has beenwithheld nor any relevant circumstances omitted. I agree to the Company seeking information in connection with this claim from anysource and I authorise the giving of such information. A photocopy of this authorisation is as valid as the original.Signature of PolicyholderName :NRIC/ Passport No :Date :Claims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sg3

LIFE WOMAN ENHANCED BENEFITS CLAIMDOCTOR’S STATEMENTImportant Note:The below named is insured with The Overseas Assurance Corporation Limited against the happening of certain contingent eventsassociated with his / her health. A claim has been submitted and to enable us to assess the claim, we would be obliged if you wouldcomplete this doctor ’s statement. The fees for the completion of this form shall be paid by the claimant* Please delete where appropriateName of Life Assured:NRIC / Passport No.:1. When were you first consulted for this illness, and in your opinion, how long had the symptoms been present?2. What were the symptoms that the Life Assured complained and for how long had she been experiencing these symptoms?3. Is the condition for which the Life Assured is being treated in any way connected to the following?(Please tick appropriate box)Carcinoma in situ of the breastCarcinoma in situ of the cervix uteriSLE with lupus nephritisHysterectomy required as a result of cancerEctopic PregnancyDown’s syndromeSpina bifidaTetralogy of FallotTransposition of the Great VesselsDisseminated Intravascular coagulationReconstructive surgery of facial disfigurement due to accident or assaultNote:i. In the case of female cancer, carcinoma in situ or systemic lupus erythematosus, please describe in full detail and pleaseinclude evidence which led to the diagnosis being made (e.g. histopathological reports)ii.Should the claim involve a congenital anomaly, please attach supporting evidence regarding diagnosis of such (e.g. X-rays,echocardiogram)DateSignature of DoctorThe Great Eastern Life Assurance Company Limited (Reg. No. 1908 00011G)The Overseas Assurance Corporation Limited (Reg. No. 1920 00003W)Claims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sg1

4. Please provide full and exact details of the diagnosis and its clinical basis.5. On which date was the diagnosis made?Day Month Year6. Please provide the name and address of the doctor:(a)who had referred the Life Assured to you.(b)to whom you had referred this Life Assured.7. Has the Life Assured previously suffered from similar illness or any related condition? YES / NO*If “YES”, please provide details including date(s) of diagnosis, treatment and doctor(s) consulted.8. Is the Life Assured suffering from any chronic sickness or disease? YES / NO*If “YES”, what is he/she suffering from and for how long?9. Are you aware of anything in the Life Assured’s previous history that is likely to have contributed to her present condition?10. Please provide any other information which may be of assistance to us in assessing this claim.DateSignature & Official Stamp of DoctorClaims Department1 Pickering Street #13-01 Great Eastern Centre Singapore 048659 Tel: 1800-248 2888 Fax: 6532 4406Email: Claims@lifeisgreat.com.sg Website: www.lifeisgreat.com.sg2